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Calvin AD, Dexter D, Beckermann J, Hayes SN, Manning CK, Helmers RA. Adopting academic rank in a rural community practice affiliated with an academic medical center. BMC MEDICAL EDUCATION 2024; 24:879. [PMID: 39143503 PMCID: PMC11325737 DOI: 10.1186/s12909-024-05844-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 07/30/2024] [Indexed: 08/16/2024]
Abstract
BACKGROUND United States rural community-based practices are increasingly participating in undergraduate and graduate medical education to train the workforce of the future, and are required or encouraged to provide academic appointments to physicians who have typically not held an academic appointment. Mechanisms to identify faculty and award academic appointments across an entire health system have not been reported. METHODS Our rural community regional practice identified academic appointments as important for participating in medical education. Over a three-year period, our regional leadership organized a formal education committee that led a variety of administrative changes to promote the adoption of academic rank. Data on attainment of academic appointments was obtained from our Academic Appointment and Promotion Committee, and cross referenced with data from our regional human resources department using self-reported demographic data. RESULTS We describe a successful adoption strategy for awarding academic rank in a rural regional practice in which the percentage of physician staff with academic rank increased from 41.1 to 92.8% over a 3-year period. CONCLUSIONS Our experience shows that process changes can rapidly increase and then sustain academic appointments for physicians over time. More rural health systems may want to consider the use of academic rank to support educational programs while enhancing physician satisfaction, recruitment and retention.
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Affiliation(s)
- Andrew D Calvin
- Department of Cardiovascular Medicine, Mayo Clinic Health System, Eau Claire, WI, USA.
| | - Donn Dexter
- Department of Neurology, Mayo Clinic Health System, Eau Claire, WI, USA
| | - Jason Beckermann
- Department of Surgery, Mayo Clinic Health System, Eau Claire, WI, USA
| | - Sharonne N Hayes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Carmen K Manning
- College of Health and Human Sciences, University of Wisconsin - Eau Claire, Eau Claire, WI, USA
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Sechrist S, Margol V, Martinez A. Redefining the term "Disadvantaged student": A post baccalaureate program's role in underrepresented students' success and reclaiming of narratives. J Natl Med Assoc 2024; 116:309-319. [PMID: 38816265 DOI: 10.1016/j.jnma.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 01/31/2024] [Accepted: 05/08/2024] [Indexed: 06/01/2024]
Abstract
PURPOSE Racial/ethnic minority groups and low-income students continue to be underrepresented in medicine (URiM) despite years of diversity and inclusion efforts. Post baccalaureate programs (PBP) are shown to prepare underrepresented students to successfully matriculate to medical school. However, identification of the aspects of a PBP that are key to future success in medicine from the student perspective is lacking. Therefore, this study was designed to answer the question, "What aspects of a post baccalaureate program do URiM students see as valuable to their future success?" METHODS This is a qualitative analysis of semi-structured interviews with alumni of the UCSF PBP who completed the program between 2015-2020. Interviews were conducted via phone or video call, audio recorded, and transcribed verbatim. Names and years of attendance were removed from the transcripts prior to review to protect confidentiality. Transcripts were coded following an inductive qualitative approach using methodology rooted in grounded theory. Demographic data was collected upon enrollment in the program. RESULTS Forty study participants were interviewed (58% of eligible subjects). Participants self-identified as Latinx (70%), African American (8%), Southeast Asian (10%), Native American (2%), Multiethnic (10%), and 60% female. The average age at enrollment was 24 years. Most participants (75%) were first-generation college students and 85% grew up with a family income <$49,999. Qualitative findings were categorized into five main themes: (1) Academic, Professional, and Personal Skills Development, (2) Supportive Student Cohort, (3) Resources, Personalized Advising, and Mentorship, (4) Gaining Confidence and a Sense of Belonging in Medicine, and (5) Redefining "Disadvantaged" Status. A novel finding was the importance of redefining the narrative of belonging to a "disadvantaged" community. During the program, the study participants reported gaining confidence and a sense of belonging in medicine as they recognized the unique qualifications and advantages they bring to medicine. CONCLUSIONS Our findings suggest that in addition to academic preparation, PBPs for students who are underrepresented in medicine should empower students to recognize their strengths and qualifications in the field of medicine. Our study participants rejected the term "disadvantaged" as they celebrated the value of their backgrounds and what they bring to medicine.
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Affiliation(s)
- Samantha Sechrist
- School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Valerie Margol
- Post Baccalaureate & Outreach Programs, University of California San Francisco, San Francisco, California, USA
| | - Alma Martinez
- Post Baccalaureate & Outreach Programs, University of California San Francisco, San Francisco, California, USA; Department of Pediatrics, University of California San Francisco, San Francisco, California, USA.
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Moazzam Z, Woldesenbet S, Munir MM, Alaimo L, Lima H, Ashraf A, Endo Y, Pawlik TM. Immigrant Doctors and Their Role in US Healthcare. J Gastrointest Surg 2023; 27:2724-2732. [PMID: 37950096 DOI: 10.1007/s11605-023-05878-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/25/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND The composition of the US healthcare workforce relative to citizenship status remains ill-defined. We sought to characterize practice patterns among US doctors relative to citizenship status. MATERIALS AND METHODS Data were extracted from the 2008-2019 American Community Surveys, and citizenship was stratified as: citizens by birth, naturalized citizens for ≥ 10 years or < 10 years, and non-citizens. Multinomial logistic regression models and inverse probability weighting were employed. The data were reported as differences in proportions/means with 95% confidence intervals. RESULTS Among 97,775,606 respondents, 113,638 were identified as doctors (0.12%). Among the surveyed doctors, 72.4% (95% CI 72.1-72.8%) were citizens by birth, followed by naturalized citizens ≥ 10 years [14.4% (95% CI 14.1-14.6%)], non-citizens [7.2% (95% CI 7.0-7.4%)], and naturalized citizens < 10 years [6.0% (95% CI 5.8-6.1%)]. Naturalized citizens ≥ 10 and < 10 years worked 40.4 (95% CI 12.6-68.2) and 38.2 (95% CI 4.8-71.6) more hours annually compared with citizens by birth, respectively (both p < 0.05). While 22.7% of doctors who were citizens by birth worked in high socially vulnerable counties, immigrant doctors were more likely to work in these areas (difference (95% CI); naturalized citizens ≥ 10 years, 7.7% (6.1-9.4) vs. naturalized citizens < 10 years, 8.0% (5.9-10.1) vs. non-citizens, 4.1% (2.0-6.1)). Furthermore, naturalized citizens ≥ 10 years and < 10 years worked in lower physician density counties that had 29.6 (14.4-44.8) and 59.9 (42.3-77.5) more people, respectively, relative to doctors (all p < 0.001). CONCLUSIONS Immigrant doctors play a vital role in addressing US healthcare needs. Policies that encourage the increased integration and utilization of immigrant doctors and physicians-in-training may help to foster a sustainable healthcare workforce over the coming decades.
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Affiliation(s)
- Zorays Moazzam
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA
| | - Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA
| | - Laura Alaimo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA
| | - Henrique Lima
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA
| | - Alina Ashraf
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA.
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de Figueiredo AM, de Labry Lima AO, de Figueiredo DCMM, Neto AJDM, Rocha EMS, de Azevedo GD. Educational Strategies to Reduce Physician Shortages in Underserved Areas: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:5983. [PMID: 37297587 PMCID: PMC10252282 DOI: 10.3390/ijerph20115983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/20/2023] [Accepted: 05/22/2023] [Indexed: 06/12/2023]
Abstract
The shortage of physicians in rural and underserved areas is an obstacle to the implementation of Universal Health Coverage (UHC). We carried out a systematic review to analyze the effectiveness of initiatives in medical education aimed to increase the supply of physicians in rural or underserved areas. We searched for studies published between 1999 and 2019 in six databases, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Interventional or observational controlled studies were defined as inclusion criteria. A total of 955 relevant unique records were selected for inclusion, which resulted in the identification of 17 articles for analysis. The admission of students from rural areas associated with a rural curriculum represented 52.95% of the interventions. Medical practice after graduation in rural or underserved areas was the most evaluated outcome, representing 12 publications (70.59%). Participants of these educational initiatives were more likely to work in rural or underserved areas or to choose family medicine, with significant differences between the groups in 82.35% of the studies. Educational strategies in undergraduate and medical residencies are effective. However, it is necessary to expand these interventions to ensure the supply of physicians in rural or urban underserved areas.
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Affiliation(s)
- Alexandre Medeiros de Figueiredo
- Department of Health Promotion, Federal University of Paraíba, Campus I, Jardim Universitário, S/N, Castelo Branco, João Pessoa 58051-900, Paraiba, Brazil
- Health Sciences Postgraduate Program, Federal University do Rio Grande do Norte, Campus Universitário Lagoa Nova, Natal 59078-900, Rio Grande do Norte, Brazil
| | - Antonio Olry de Labry Lima
- Andalusian School of Public Health, Cuesta del Observatorio 4, Campus Universitario de Cartuja, 18011 Granada, Andalusia, Spain
| | | | - Alexandre José de Melo Neto
- Department of Health Promotion, Federal University of Paraíba, Campus I, Jardim Universitário, S/N, Castelo Branco, João Pessoa 58051-900, Paraiba, Brazil
| | - Erika Maria Sampaio Rocha
- Health Science Training Center, Federal University of Espírito Santo, Av. Fernando Ferrari, 514, Goiabeiras, Vitória 29075-910, Espirito Santo, Brazil
| | - George Dantas de Azevedo
- Multicampi School of Medical Sciences, Federal University of Rio Grande do Norte, Av. Cel Martiniano, 541, Caico 59300-000, Rio Grande do Norte, Brazil
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Mason HRC, Ata A, Nguyen M, Nakae S, Chakraverty D, Eggan B, Martinez S, Jeffe DB. First-generation and continuing-generation college graduates' application, acceptance, and matriculation to U.S. medical schools: a national cohort study. MEDICAL EDUCATION ONLINE 2022; 27:2010291. [PMID: 34898403 PMCID: PMC8676688 DOI: 10.1080/10872981.2021.2010291] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 11/10/2021] [Accepted: 11/20/2021] [Indexed: 06/13/2023]
Abstract
Many U.S. medical schools conduct holistic review of applicants to enhance the socioeconomic and experiential diversity of the physician workforce. The authors examined the role of first-generation college-graduate status on U.S. medical school application, acceptance, and matriculation, hypothesizing that first-generation (vs. continuing-generation) college graduates would be less likely to apply and gain acceptance to medical school.Secondary analysis of de-identified data from a retrospective national-cohort study was conducted for individuals who completed the 2001-2006 Association of American Medical Colleges (AAMC) Pre-Medical College Admission Test Questionnaire (PMQ) and the Medical College Admissions Test (MCAT). AAMC provided medical school application, acceptance, and matriculation data through 06/09/2013. Multivariable logistic regression models identified demographic, academic, and experiential variables independently associated with each outcome and differences between first-generation and continuing-generation students. Of 262,813 PMQ respondents, 211,216 (80.4%) MCAT examinees had complete data for analysis and 24.8% self-identified as first-generation college graduates. Of these, 142,847 (67.6%) applied to U.S. MD-degree-granting medical schools, of whom 86,486 (60.5%) were accepted, including 14,708 (17.0%) first-generation graduates; 84,844 (98.1%) acceptees matriculated. Adjusting for all variables, first-generation (vs. continuing-generation) college graduates were less likely to apply (odds ratio [aOR] 0.84; 95% confidence interval [CI], 0.82-0.86) and be accepted (aOR 0.86; 95% CI, 0.83-0.88) to medical school; accepted first-generation college graduates were as likely as their continuing-generation peers to matriculate. Students with (vs. without) paid work experience outside hospitals/labs/clinics were less likely to apply, be accepted, and matriculate into medical school. Increased efforts to mitigate structural socioeconomic vulnerabilities that may prevent first-generation college students from applying to medical school are needed. Expanded use of holistic review admissions practices may help decision makers value the strengths first-generation college graduates and other underrepresented applicants bring to medical educationand the physician workforce.
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Affiliation(s)
- Hyacinth R. C. Mason
- Department of Medical Education Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Ashar Ata
- Department of Surgery and Emergency Medicine, Albany Medical Center, Albany, New York, USA
| | - Mytien Nguyen
- Yale University, School of Medicine, New Haven, Connecticut, USA
| | - Sunny Nakae
- Medical Education, California University of Science and Medicine, Colton, California, USA
| | - Devasmita Chakraverty
- Ravi J. Matthai Centre for Educational Innovation, Indian Institute of Management Ahmedabad, Ahmedabad, India
| | - Branden Eggan
- Department of Nursing, Siena College, Loudonville, New York, USA
| | | | - Donna B. Jeffe
- Department of Medicine, Director, Medical Education Research Unit, Office of Education, Washington University School of Medicine, St. Louis, Missouri, USA
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Rabinowitz HK, Motley RJ, Markham FW, Love GA. Lessons Learned as Thomas Jefferson University's Rural Physician Shortage Area Program (PSAP) Approaches the Half-Century Mark. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:1264-1267. [PMID: 35442906 DOI: 10.1097/acm.0000000000004710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
To help increase the supply and retention of rural family physicians, Thomas Jefferson University initiated the Physician Shortage Area Program (PSAP) in 1974. The program selectively admits medical school applicants who both grew up in a rural area and plan to practice in a rural area. During medical school, PSAP students have ongoing mentoring and rural clinical experiences. As the program now approaches the half-century mark, this commentary summarizes several important lessons learned. First, outcomes research is critical, and program leaders have been able to publish 15 papers and a book about the PSAP and its outcomes. Second, these studies have shown that the program has been highly successful, with PSAP graduates 8.5-9.9 times more likely to enter rural family medicine than their peers, and that the PSAP contributed 12% of all rural family physicians in Pennsylvania. Other similar medical school rural programs have had comparable success, with more than half of all graduates combined (including PSAP graduates) practicing rural. Third, long-term retention has a multiplicative impact. Long-term retention of PSAP graduates in rural family medicine was greater than 70% after 20-25 years. Fourth, research has shown that the admissions component accounted for approximately three-quarters of the PSAP's success. Three factors available at the time of matriculation (rural background, plans for rural practice, and plans for family medicine) identified almost 80% of all Jefferson graduates in rural practice 3 decades later. Having a peer group with similar backgrounds, mentoring, and the rural curriculum were also very important. Fifth, wanting to live rural appears key to the rural practice decision. Finally, given that medical school programs like the PSAP produce substantial increases in the supply and retention of rural physicians while requiring modest resources, medical schools can have a critical role in addressing the rural physician shortage.
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Affiliation(s)
- Howard K Rabinowitz
- H.K. Rabinowitz is professor emeritus, family and community medicine, and director emeritus, Physician Shortage Area Program, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Robert J Motley
- R.J. Motley is the Ellen M. and Dale W. Garber Professor of Family and Community Medicine and director, Physician Shortage Area Program, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Fred W Markham
- F.W. Markham is professor, family and community medicine, and associate director, Physician Shortage Area Program, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Gillian A Love
- G.A. Love is assistant professor, family and community medicine, and assistant director, Physician Shortage Area Program, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
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Elma A, Nasser M, Yang L, Chang I, Bakker D, Grierson L. Medical education interventions influencing physician distribution into underserved communities: a scoping review. HUMAN RESOURCES FOR HEALTH 2022; 20:31. [PMID: 35392954 PMCID: PMC8991572 DOI: 10.1186/s12960-022-00726-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/24/2022] [Indexed: 06/09/2023]
Abstract
BACKGROUND AND OBJECTIVE Physician maldistribution is a global problem that hinders patients' abilities to access healthcare services. Medical education presents an opportunity to influence physicians towards meeting the healthcare needs of underserved communities when establishing their practice. Understanding the impact of educational interventions designed to offset physician maldistribution is crucial to informing health human resource strategies aimed at ensuring that the disposition of the physician workforce best serves the diverse needs of all patients and communities. METHODS A scoping review was conducted using a six-stage framework to help map current evidence on educational interventions designed to influence physicians' decisions or intention to establish practice in underserved areas. A search strategy was developed and used to conduct database searches. Data were synthesized according to the types of interventions and the location in the medical education professional development trajectory, that influence physician intention or decision for rural and underserved practice locations. RESULTS There were 130 articles included in the review, categorized according to four categories: preferential admissions criteria, undergraduate training in underserved areas, postgraduate training in underserved areas, and financial incentives. A fifth category was constructed to reflect initiatives comprised of various combinations of these four interventions. Most studies demonstrated a positive impact on practice location, suggesting that selecting students from underserved or rural areas, requiring them to attend rural campuses, and/or participate in rural clerkships or rotations are influential in distributing physicians in underserved or rural locations. However, these studies may be confounded by various factors including rural origin, pre-existing interest in rural practice, and lifestyle. Articles also had various limitations including self-selection bias, and a lack of standard definition for underservedness. CONCLUSIONS Various educational interventions can influence physician practice location: preferential admissions criteria, rural experiences during undergraduate and postgraduate medical training, and financial incentives. Educators and policymakers should consider the social identity, preferences, and motivations of aspiring physicians as they have considerable impact on the effectiveness of education initiatives designed to influence physician distribution in underserved locations.
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Affiliation(s)
- Asiana Elma
- Department of Family Medicine, Faculty of Health Sciences, David Braley Health Sciences Center, McMaster University, 100 Main St. W., Hamilton, ON, L8P 1H6, Canada
| | - Muhammadhasan Nasser
- Bachelor of Health Sciences Program, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Laurie Yang
- Bachelor of Health Sciences Program, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Irene Chang
- Bachelor of Health Sciences Program, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Dorothy Bakker
- Department of Family Medicine, Faculty of Health Sciences, David Braley Health Sciences Center, McMaster University, 100 Main St. W., Hamilton, ON, L8P 1H6, Canada
- McMaster Community and Rural Education Program, McMaster University, Hamilton, Canada
| | - Lawrence Grierson
- Department of Family Medicine, Faculty of Health Sciences, David Braley Health Sciences Center, McMaster University, 100 Main St. W., Hamilton, ON, L8P 1H6, Canada.
- McMaster Community and Rural Education Program, McMaster University, Hamilton, Canada.
- McMaster Education Research, Innovation and Theory, Faculty of Health Sciences, McMaster University, Hamilton, Canada.
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Lo Sasso AT. Regulating high-skilled immigration: The market for medical residents. JOURNAL OF HEALTH ECONOMICS 2021; 76:102436. [PMID: 33556781 DOI: 10.1016/j.jhealeco.2021.102436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 12/24/2020] [Accepted: 01/18/2021] [Indexed: 06/12/2023]
Abstract
The effect of high-skill immigration remains central to many US industries and policy debates. Beginning in 2009, the federal government heightened enforcement of existing laws and increased employer fees for the cost of obtaining certain common immigration visas. The change can be viewed as a de facto tax on immigrant labor. I estimate the extent to which high-skill non-citizen workers, in the form of international medical school graduates seeking residency training in US teaching hospitals, are displaced by US citizens who received their medical school training abroad. Changes in immigration policy can have important effects in this labor market with implications for the larger health care system. I find that demand for medical residents among teaching hospitals based on immigration status is highly responsive to increased regulatory cost.
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Affiliation(s)
- Anthony T Lo Sasso
- Department of Economics, DePaul University, 1 East Jackson, Chicago, IL, 60604, United States.
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Saito H, Tanimoto T, Kami M, Suzuki Y, Morita T, Morita M, Yamamoto K, Shimada Y, Tsubokura M, Endo M. New physician specialty training system impact on distribution of trainees in Japan. Public Health 2020; 182:143-150. [PMID: 32305513 DOI: 10.1016/j.puhe.2020.02.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 01/13/2020] [Accepted: 02/07/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The problem of uneven distribution of medical services and inequitable distribution of physicians is drawing much attention worldwide. Revealing how changes in the specialty training system in Japan have affected the distribution of doctors could help us understand this problem. In 2018, a new and standardized specialty training system was implemented by the Japanese Medical Specialty Board, which is recognized by the Ministry of Health, Labor and Welfare. The purpose of this study was to investigate how this new system has affected the geographical distribution of doctors commencing specialty training (trainees) and choice of specialty in Japan. STUDY DESIGN Retrospective observational study. METHODS The change in the number of trainees between the control period (2012-2014) and 2018 was investigated, taking into account the prefecture and specialty selected. Population, the proportion of residents aged 65 years or older (aging rate), and the total number of overall doctors in each prefecture were considered as the background characteristics of each prefecture. We created a Lorenz curve and calculated the Gini coefficient for the distribution of trainees. RESULTS In 2018, the number of trainees per 100,000 population increased to 6.6 nationwide compared with 5.5 during the control period. The number of trainees per 100,000 population in 2018 increased in prefectures with a large population of ≧ 2,000,000, a low aging rate (<27%), and a high doctor density (≧ 250 doctors per 100,000 population). The Gini coefficient showed an increase to 0.226 in 2018 compared with only 0.160 during the control period. CONCLUSIONS After the implementation of the new training system, there was an increase in the number of doctors enrolling in specialty programs, and the specialties other than internal medicine and surgery have attracted more trainees. Inequality in the distribution of doctors between urban and rural prefectures worsened. This indicates the need to explore new ways of balancing distribution while maintaining optimal opportunities for specialist training.
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Affiliation(s)
- H Saito
- Department of Gastroenterology, Sendai Kousei Hospital, Sendai, Miyagi, Japan.
| | - T Tanimoto
- Department of Internal Medicine, Navitas Clinic, Tachikawa, Tokyo, Japan
| | - M Kami
- Medical Governance Research Institute, Minato-ku, Tokyo, Japan
| | - Y Suzuki
- Department of Obstetrics and Gynecology, Tone Central Hospital, Numata, Gunma, Japan
| | - T Morita
- Department of Internal Medicine, Soma Central Hospital, Soma, Fukushima, Japan
| | - M Morita
- Medical Governance Research Institute, Minato-ku, Tokyo, Japan
| | - K Yamamoto
- Medical Governance Research Institute, Minato-ku, Tokyo, Japan
| | - Y Shimada
- Department of Neurosurgery, Minamisoma Municipal General Hospital, Minamisoma, Fukushima, Japan
| | - M Tsubokura
- Department of Internal Medicine, Soma Central Hospital, Soma, Fukushima, Japan
| | - M Endo
- Support Office for Medical Education and Trainings, Sendai Kousei Hospital, Sendai, Miyagi, Japan
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O Carroll A, O’Reilly F. Medicine on the margins. An innovative GP training programme prepares GPs for work with underserved communities. EDUCATION FOR PRIMARY CARE 2019; 30:375-380. [DOI: 10.1080/14739879.2019.1670738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- A. O Carroll
- MICGP, DHealth North Dublin City GP Training Programme
| | - F. O’Reilly
- RGN, RSCN, North Dublin City GP Training Programme
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Geier AK, Saur C, Lippmann S, Nafziger M, Frese T, Deutsch T. LeiKA: an optional German general practice teaching project for first-semester medical students: who is taking part and why? A cross-sectional study. BMJ Open 2019; 9:e032136. [PMID: 31676656 PMCID: PMC6830716 DOI: 10.1136/bmjopen-2019-032136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES This study investigates students' adoption of LeiKA, a new extracurricular longitudinal general practice (GP) teaching project. LeiKA aims to attract a broad range of students, not only those who are already planning to become GPs. This study compares participants' and non-participants' characteristics, career preferences and job-related value orientations to assess the programme's initial potential to increase the number of students subsequently entering GP careers. Additionally, students' motives for taking part in the programme were explored. DESIGN We analysed administrative data and data from a cross-sectional questionnaire survey for the first three cohorts. LeiKA participants were compared with non-participants regarding baseline characteristics, career intentions and attitudes associated with GP careers. There was also a qualitative analysis of the reasons for taking part. SETTING Faculty of Medicine, University of Leipzig, Germany. PARTICIPANTS First-semester medical students in the years 2016-2018. RESULTS In the first 3 years, 86 of 90 LeiKA slots were taken, 9.0% (n=86/960) of those eligible to apply. LeiKA participants were a mean of 0.6 years older (LeiKA: 21.5 vs whole cohort: 20.9 years, p<0.001) and slightly more interested in long-term doctor-patient relationships (3.6 vs 3.3, scale from 1 'unimportant' to 5 'very important', p=0.018), but did not differ regarding other characteristics and attitudes. Although more participants definitely favoured a GP career (13.1% vs 4.9%, p=0.001), it was a possible option for most students in both groups (78.6% vs 74.0%). Early acquisition of skills and patient contact were the main motives for taking part, stated by 60.7% and 41.7% of the participants, respectively. CONCLUSIONS The extracurricular programme was taken up by a broad range of students, indicating its potential to attract more students to become GPs. The reasons for taking part that we identified may guide the planning of other similar projects.
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Affiliation(s)
- Anne-Kathrin Geier
- Department of General Practice, University of Leipzig, Faculty of Medicine, Leipzig, Germany
| | - Christiane Saur
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital Leipzig, Leipzig, Germany
| | - Stefan Lippmann
- Department of General Practice, University of Leipzig, Faculty of Medicine, Leipzig, Germany
| | - Melanie Nafziger
- Institute of General Practice and Family Medicine, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - T Frese
- Institute of General Practice and Family Medicine, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Tobias Deutsch
- Department of General Practice, University of Leipzig, Faculty of Medicine, Leipzig, Germany
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Playford D, Ngo H, Atkinson D, Puddey IB. Graduate doctors' rural work increases over time. MEDICAL TEACHER 2019; 41:1073-1080. [PMID: 31177927 DOI: 10.1080/0142159x.2019.1621278] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Background: The contribution of rural clinical school (RCS) and rural origin to developing a long-term rural medical workforce was examined. Methods: Longitudinal cohort study, after undergraduate location in either rural or urban setting, for all medical graduates 2004-2010, identified in the Australian Health Practitioner Regulation Agency, in the following groups: Urban origin/no RCS; Rural origin/no RCS; Urban origin/RCS; and Rural origin/RCS. Results: Proportions of all graduates working rurally increased from 2013 to 2018, including amongst urban origin/nonRCS graduates. Rural origin/RCS participants worked rurally at the highest rates across all time points, with an endpoint of 47%, and an odds ratio of 9.70 (5.41, 17.40) relative to the urban reference group. They had a cumulative duration of rural practice over 5 times higher than the urban reference group. RCS graduates were more likely to be working in remote areas than nonRCS graduates. Conclusion: All graduates' contribution to rural and remote workforce is dynamic and increasing. Both RCS participation and rural student recruitment make synergistic and increasing contributions to rural work. RCS effects workforce distribution to more remote areas. Single cross-sectional studies do not capture this dynamic growth in the rural workforce.
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Affiliation(s)
- Denese Playford
- The Rural Clinical School of Western Australia, The School of Medicine, The Faculty of Health and Medical Sciences, The University of Western Australia , Crawley , WA , USA
| | - Hanh Ngo
- The Rural Clinical School of Western Australia, The School of Medicine, The Faculty of Health and Medical Sciences, The University of Western Australia , Crawley , WA , USA
| | - David Atkinson
- The Rural Clinical School of Western Australia, The School of Medicine, The Faculty of Health and Medical Sciences, The University of Western Australia , Crawley , WA , USA
| | - Ian B Puddey
- School of Medicine and Pharmacology, The School of Medicine, The Faculty of Health and Medical Sciences, The University of Western Australia , Crawley , WA , USA
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Playford DE, Burkitt T, Atkinson D. Social network analysis of rural medical networks after medical school immersion in a rural clinical school. BMC Health Serv Res 2019; 19:305. [PMID: 31088454 PMCID: PMC6515657 DOI: 10.1186/s12913-019-4132-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 04/29/2019] [Indexed: 11/26/2022] Open
Abstract
Background The impact of new medical graduates on the social dimensions of the rural medical workforce is yet to be examined. Social Network Analysis (SNA) is able to visualize and measure these dimensions. We apply this method to examine the workforce characteristics of graduates from a representative Australian Rural Clinical School. Methods Participants were medical graduates of the Rural Clinical School of Western Australia (RCSWA) from the 2001–2014 cohorts, identified as being in rural work in 2017 by the Australian Health Practitioner Regulation Agency. SNA was used to examine the relationships between site of origin and of work destination. Data were entered into UCInet 6 as tied pairs, and visualized using Netdraw. UCINet statistics relating to node centrality were obtained from the node editor. Results SNA measures showed that the 124 of 709 graduates in rural practice were distributed around Australia, and that their practice was strongly focused on the North, with a clear centre in the remote Western Australian town of Broome. Women were strongly recruited, and were widely distributed. Conclusions RCSWA appears to be a “weak tie” according to SNA theory: the School attracts graduates to rural nodes where they had only passing prior contact. The multiple activities that comprise the social capital of the most attractive, remote, node demonstrate the clear workforce effects of being a “bridge, broker and boundary spanner” in SNA terms, and add new understanding about recruiting to the rural workforce.
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Affiliation(s)
- Denese E Playford
- The Rural Clinical School of Western Australia, RCSWA, M706, The School of Medicine, The University of Western Australia, Crawley, WA, 6009, Australia. .,The University of Notre Dame Australia, Fremantle Campus, Western Australia, Australia, 32 Mouat St, Fremantle, WA, 6160, Australia.
| | - Tessa Burkitt
- The Rural Clinical School of Western Australia, RCSWA, M706, The School of Medicine, The University of Western Australia, Crawley, WA, 6009, Australia.,The University of Notre Dame Australia, Fremantle Campus, Western Australia, Australia, 32 Mouat St, Fremantle, WA, 6160, Australia
| | - David Atkinson
- The Rural Clinical School of Western Australia, RCSWA, M706, The School of Medicine, The University of Western Australia, Crawley, WA, 6009, Australia.,The University of Notre Dame Australia, Fremantle Campus, Western Australia, Australia, 32 Mouat St, Fremantle, WA, 6160, Australia
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Raffoul M, Bartlett-Esquilant G, Phillips RL. Recruiting and Training a Health Professions Workforce to Meet the Needs of Tomorrow's Health Care System. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2019; 94:651-655. [PMID: 30681446 DOI: 10.1097/acm.0000000000002606] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The quality of any health care system depends on the caliber, enthusiasm, and diversity of the workforce. Yet, workforce research often focuses on the number and type of health professionals needed and anticipated shortages compared with anticipated needs. These projections do not address whether the workforce will have the requisite social, intellectual, cultural, and emotional capital needed to deliver care in an increasingly complex health care system.Building a workforce that can deliver care in such a system begins by recruiting individuals with the requisite knowledge, skills, and attributes. To address this and other workforce needs, the authors argue that health professions education programs must make purposeful changes to their admissions criteria, such as focusing on emotional intelligence and diversity and recruiting students from the communities where they will return to work; partner with communities; ensure that accreditation systems support these goals of fostering diversity; recruit students who can bridge the gap between public health and health care; and invest in health professions education research.In this article, they contemplate how health professions education programs can recruit and educate talented health professionals to create a high-performing workforce that is capable of serving in the complex health care system of tomorrow. They provide examples of successful programs to highlight the potential effects of their recommendations.
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Affiliation(s)
- Melanie Raffoul
- M. Raffoul is assistant professor, Department of Emergency Medicine, and assistant medical director, Tisch Observation/Short Stay Unit, NYU Langone Health, New York, New York. G. Bartlett-Esquilant is professor, associate chair, and research and graduate program director, Department of Family Medicine, McGill University, Montreal, Quebec, Canada. R.L. Phillips Jr is executive director, Center for Professionalism and Value in Health Care, American Board of Family Medicine, Lexington, Kentucky, and professor, Department of Family Medicine, Georgetown University, Washington, DC
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McGrail MR, O’Sullivan BG, Russell DJ. Rural training pathways: the return rate of doctors to work in the same region as their basic medical training. HUMAN RESOURCES FOR HEALTH 2018; 16:56. [PMID: 30348164 PMCID: PMC6198494 DOI: 10.1186/s12960-018-0323-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 10/10/2018] [Indexed: 05/28/2023]
Abstract
BACKGROUND Limited evidence exists about the extent to which doctors are returning to rural region(s) where they had previously trained. This study aims to investigate the rate at which medical students who have trained for 12 months or more in a rural region return to practice in that same region in their early medical career. A secondary aim is to investigate whether there is an independent or additional association with the effect of longer duration of rural exposure in a region (18-24 months) and for those completing both schooling and training in the same rural region. METHODS The outcome was rural region of work, based on postcode of work location in 2017 for graduates spanning 1-9 years post-graduation, for one large medical program in Victoria, Australia. Region of rural training, combined with region of secondary schooling and duration of rural training, was explored for its association with region of practice. A multinomial logistic regression model, accounting for other covariates, measured the strength of association with practising in the same rural region as where they had trained. RESULTS Overall, 357/2451 (15%) graduates were working rurally, with 90/357 (25%) working in the same rural region as where they did rural training. Similarly, 41/170 (24%) were working in the same region as where they completed schooling. Longer duration (18-24 vs 12 months) of rural training (relative risk ratio, RRR, 3.37, 1.89-5.98) and completing both schooling and training in the same rural region (RRR: 4.47, 2.14-9.36) were associated with returning to practice in the same rural region after training. CONCLUSIONS Medical graduates practising rurally in their early career (1-9 years post-graduation) are likely to have previous connections to the region, through either their basic medical training, their secondary schooling, or both. Social accountability of medical schools and rural medical workforce outcomes could be improved by policies that enable preferential selection and training of prospective medical students from rural regions that need more doctors, and further enhanced by longer duration of within-region training.
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Affiliation(s)
- Matthew R. McGrail
- University of Queensland, Rural Clinical School, 78 on Canning Street, Rockhampton, QLD 4700 Australia
| | - Belinda G. O’Sullivan
- Monash Rural Health, Monash University, 26 Mercy Street, Bendigo, VIC 3550 Australia
| | - Deborah J. Russell
- Flinders University, Northern Territory, PO Box 41326, Casuarina, NT 0815 Australia
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Johnson GE, Wright FC, Foster K. The impact of rural outreach programs on medical students' future rural intentions and working locations: a systematic review. BMC MEDICAL EDUCATION 2018; 18:196. [PMID: 30107795 PMCID: PMC6092777 DOI: 10.1186/s12909-018-1287-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 07/19/2018] [Indexed: 05/07/2023]
Abstract
BACKGROUND Significant investment has been undertaken by many countries into 'Rural Clinical Training Placement Schemes' for medical students in order to deal with shortages of trained health care professionals in rural and remote locations. This systematic review examines the evidence base of rural educational programs within medical education and focusses on workforce intentions and employment outcomes. The study provides a detailed description of the methodological characteristics of the literature, thematic workforce outcomes and key related factors are identified, study quality is assessed, and the findings are compared within an international context. METHODS A systematic review looking at international literature of rural placement programs within medical education between January 2005 to January 2017 from databases including; Medline, Embase, NursingOVID, PubMed and Cochrane. The study adopted the PRISMA protocol. A quality assessment of the literature was conducted based on the Health Gains Notation Framework. RESULTS Sixty two papers met the inclusion criteria. The review identified three program classifications; Rural Clinical Placement Programs, Rural Clinical Placement Programs combined with a rural health educational curriculum component and Rural Clinical School Programs. The studies included were from Australia, United States, Canada, New Zealand, Thailand and Africa. Questionnaires and tracking or medical registry databases were the most commonly reported research tools and the majority were volunteer programs. Most studies identified potential rural predictors/confounders, however a number did not apply control groups and most programs were based on a single site. There was a clear discrepancy in the ideal rural clinical placement length. Outcomes themes were identified related to rural workforce outcomes. Most studies reported that an organised, well-funded, rural placement or rural clinical school program produced positive associations with increased rural intentions and actual graduate rural employment. CONCLUSIONS Future research should focus on large scale methodologically rigorous multi-site rural program studies, with longitudinal follow up of graduates working locations. Studies should apply pre-and post-intervention surveys to measure change in attitudes and control for predictive confounders, control groups should be applied; and in-depth qualitative research should be considered to explore the specific factors of programs that are associated with encouraging rural employment.
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Affiliation(s)
- George E. Johnson
- Sydney Medical School, University of Sydney, Sydney, NSW 2050 Australia
| | - Fredrick Clive Wright
- Concord Clinical School, University of Sydney, Sydney, Australia
- Centre for Education and Research on Ageing, Sydney, NSW 2139 Australia
| | - Kirsty Foster
- Sydney Medical School, Northern & Kolling Institute, University of Sydney, Sydney, NSW Australia
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McGrail MR, Wingrove PM, Petterson SM, Bazemore AW. Mobility of US Rural Primary Care Physicians During 2000-2014. Ann Fam Med 2017; 15:322-328. [PMID: 28694267 PMCID: PMC5505450 DOI: 10.1370/afm.2096] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 01/23/2017] [Accepted: 02/08/2017] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Despite considerable investment in increasing the number of primary care physicians in rural shortage areas, little is known about their movement rates and factors influencing their mobility. We aimed to characterize geographic mobility among rural primary care physicians, and to identify location and individual factors that influence such mobility. METHODS Using data from the American Medical Association Physician Masterfile for each clinically active US physician, we created seven 2-year (biennial) mobility periods during 2000-2014. These periods were merged with county-level "rurality," physician supply, economic characteristics, key demographic measures, and individual physician characteristics. We computed (1) mobility rates of physicians by rurality; (2) linear regression models of county-level rural nonretention (departure); and (3) logit models of physicians leaving rural practice. RESULTS Biennial turnover was about 17% among physicians aged 45 and younger, compared with 9% among physicians aged 46 to 65, with little difference between rural and metropolitan groups. County-level physician mobility was higher for counties that lacked a hospital (absolute increase = 5.7%), had a smaller population size, and had lower primary care physician supply, but area-level economic and demographic factors had little impact. Female physicians (odds ratios = 1.24 and 1.46 for those aged 45 or younger and those aged 46 to 65, respectively) and physicians born in a metropolitan area (odds ratios = 1.75 and 1.56 for those aged 45 or younger and those aged 46 to 65, respectively) were more likely to leave rural practice. CONCLUSIONS These flndings provide national-level evidence of rural physician mobility rates and factors associated with both county-level retention and individual-level departures. Outcomes were notably poorer in the most remote locations and those already having poorer physician supply and professional support. Rural health workforce planners and policymakers must be cognizant of these key factors to more effectively target retention policies and to take into account the additional support needed by these more vulnerable communities.
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Affiliation(s)
- Matthew R McGrail
- Monash University, School of Rural Health, Churchill, Victoria, Australia .,Centre of Research Excellence in Rural and Remote Primary Health Care, Bendigo, Victoria, Australia
| | - Peter M Wingrove
- Robert Graham Center for Policy Studies in Family Medicine and Primary Care, Washington, DC
| | - Stephen M Petterson
- Robert Graham Center for Policy Studies in Family Medicine and Primary Care, Washington, DC
| | - Andrew W Bazemore
- Robert Graham Center for Policy Studies in Family Medicine and Primary Care, Washington, DC
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Goodfellow A, Ulloa JG, Dowling PT, Talamantes E, Chheda S, Bone C, Moreno G. Predictors of Primary Care Physician Practice Location in Underserved Urban or Rural Areas in the United States: A Systematic Literature Review. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2016; 91:1313-21. [PMID: 27119328 PMCID: PMC5007145 DOI: 10.1097/acm.0000000000001203] [Citation(s) in RCA: 123] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
PURPOSE The authors conducted a systematic review of the medical literature to determine the factors most strongly associated with localizing primary care physicians (PCPs) in underserved urban or rural areas of the United States. METHOD In November 2015, the authors searched databases (MEDLINE, ERIC, SCOPUS) and Google Scholar to identify published peer-reviewed studies that focused on PCPs and reported practice location outcomes that included U.S. underserved urban or rural areas. Studies focusing on practice intentions, nonphysicians, patient panel composition, or retention/turnover were excluded. They screened 4,130 titles and reviewed 284 full-text articles. RESULTS Seventy-two observational or case-control studies met inclusion criteria. These were categorized into four broad themes aligned with prior literature: 19 studies focused on physician characteristics, 13 on financial factors, 20 on medical school curricula/programs, and 20 on graduate medical education (GME) programs. Studies found significant relationships between physician race/ethnicity and language and practice in underserved areas. Multiple studies demonstrated significant associations between financial factors (e.g., debt or incentives) and underserved or rural practice, independent of preexisting trainee characteristics. There was also evidence that medical school and GME programs were effective in training PCPs who locate in underserved areas. CONCLUSIONS Both financial incentives and special training programs could be used to support trainees with the personal characteristics associated with practicing in underserved or rural areas. Expanding and replicating medical school curricula and programs proven to produce clinicians who practice in underserved urban or rural areas should be a strategic investment for medical education and future research.
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Affiliation(s)
- Amelia Goodfellow
- A. Goodfellow is a medical student, David Geffen School of Medicine at University of California, Los Angeles (UCLA), Los Angeles, California. J.G. Ulloa is a VA/Robert Wood Johnson Foundation Clinical Scholar, UCLA, Los Angeles, California and Surgery Resident, Department of Surgery, University of California, San Francisco, San Francisco, California. P.T. Dowling is professor and chair, Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California. E. Talamantes at the time of this research was primary care research fellow, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, and is now assistant professor, Division of General Internal Medicine, Department of Internal Medicine, University of California, Davis, School of Medicine, Sacramento, California. S. Chheda is research assistant, Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California. C. Bone at the time of this research was a third-year resident physician, Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California. G. Moreno is assistant professor, Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
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19
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Pfarrwaller E, Sommer J, Chung C, Maisonneuve H, Nendaz M, Junod Perron N, Haller DM. Impact of Interventions to Increase the Proportion of Medical Students Choosing a Primary Care Career: A Systematic Review. J Gen Intern Med 2015; 30:1349-58. [PMID: 26173529 PMCID: PMC4539313 DOI: 10.1007/s11606-015-3372-9] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Increasing the attractiveness of primary care careers is a key step in addressing the growing shortage of primary care physicians. The purpose of this review was to (1) identify interventions aimed at increasing the proportion of undergraduate medical students choosing a primary care specialty, (2) describe the characteristics of these interventions, (3) assess the quality of the studies, and (4) compare the findings to those of a previous literature review within a global context. METHODS We searched MEDLINE, EMBASE, ERIC, CINAHL, PsycINFO, The Cochrane Library, and Dissertations & Theses A&I for articles published between 1993 and February 20, 2015. We included quantitative and qualitative studies reporting on primary care specialty choice outcomes of interventions in the undergraduate medical curriculum, without geographic restrictions. Data extracted included study characteristics, intervention details, and relevant outcomes. Studies were assessed for quality and strength of findings using a five-point scale. RESULTS The review included 72 articles reporting on 66 different interventions. Longitudinal programs were the only intervention consistently associated with an increased proportion of students choosing primary care. Successful interventions were characterized by diverse teaching formats, student selection, and good-quality teaching. Study quality had not improved since recommendations were published in 1995. Many studies used cross-sectional designs and non-validated surveys, did not include control groups, and were not based on a theory or conceptual framework. DISCUSSION Our review supports the value of longitudinal, multifaceted, primary care programs to increase the proportion of students choosing primary care specialties. Isolated modules or clerkships did not appear to be effective. Our results are in line with the conclusions from previous reviews and add an international perspective, but the evidence is limited by the overall low methodological quality of the included studies. Future research should use more rigorous evaluation methods and include long-term outcomes.
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Affiliation(s)
- Eva Pfarrwaller
- Primary Care Unit, Faculty of Medicine, Centre Médical Universitaire, University of Geneva, Av. de Champel 9, 1211, Genève 4, Switzerland,
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Grobler L, Marais BJ, Mabunda S. Interventions for increasing the proportion of health professionals practising in rural and other underserved areas. Cochrane Database Syst Rev 2015; 2015:CD005314. [PMID: 26123126 PMCID: PMC6791300 DOI: 10.1002/14651858.cd005314.pub3] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The inequitable distribution of health professionals, within countries, poses an important obstacle to the optimal functioning of health services. OBJECTIVES To assess the effectiveness of interventions aimed at increasing the proportion of health professionals working in rural and other underserved areas. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, including specialised register of the Cochrane Effective Practice and Organisation of Care Group; March 2014), MEDLINE (1966 to March 2014), EMBASE (1988 to March 2014), CINAHL (1982 to March 2014), LILACS (February 2014), Science Citation Index and Social Sciences Citation Index (up to April 2014), Global Health (March 2014) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (June 2013). We also searched reference lists of all papers and relevant reviews identified, and contacted authors of relevant papers regarding any further published or unpublished work. SELECTION CRITERIA Randomised trials, non-randomised trials, controlled before-and-after studies and interrupted time series studies evaluating the effects of various interventions (e.g. educational, financial, regulatory or support strategies) on the recruitment or retention, or both, of health professionals in underserved areas. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts and assessed full texts of potentially relevant studies for eligibility. Two review authors independently extracted data from eligible studies. MAIN RESULTS For this first update of the original review, we screened 8945 records for eligibility. We retrieved and assessed the full text of 125 studies. Only one study met the inclusion criteria of the review. This interrupted time series study, conducted in Taiwan, found that the implementation of a National Health Insurance scheme in 1995 was associated with improved equity in the geographic distribution of physicians and dentists. We judged the certainty of the evidence provided by this one study very low. AUTHORS' CONCLUSIONS There is currently limited reliable evidence regarding the effects of interventions aimed at addressing the inequitable distribution of health professionals. Well-designed studies are needed to confirm or refute findings of observational studies of educational, financial, regulatory and supportive interventions that might influence healthcare professionals' decisions to practice in underserved areas. Governments and medical schools should ensure that when interventions are implemented, their impacts are evaluated using scientifically rigorous methods to establish the true effects of these measures on healthcare professional recruitment and retention in rural and other underserved settings.
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Affiliation(s)
- Liesl Grobler
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesPO Box 241TygerbergCape TownWestern CapeSouth Africa8000
| | - Ben J Marais
- University of SydneyMarie Bashir Institute for Infectious Diseases and BiosecuritySydneyAustralia
- University of SydneyChildren’s Hospital at WestmeadSydneyAustralia
| | - Sikhumbuzo Mabunda
- University of Cape Town/Western Cape Department of HealthP.O. Box 768RondeboschSouth Africa7701
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Playford DE, Nicholson A, Riley GJ, Puddey IB. Longitudinal rural clerkships: increased likelihood of more remote rural medical practice following graduation. BMC MEDICAL EDUCATION 2015; 15:55. [PMID: 25879715 PMCID: PMC4372318 DOI: 10.1186/s12909-015-0332-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 02/27/2015] [Indexed: 05/16/2023]
Abstract
BACKGROUND Extended rural clerkships clearly increase the likelihood of rural practice post-graduation. What has not been determined is whether such rural interventions increase the likelihood of graduates practicing in more remote, versus inner regional, locations. METHODS The Australian Health Practitioner Regulation Agency database was used to identify the current workplace of every graduate of the Medical School of Western Australia, 1980 to 2011. There were 324 graduates working in a primary practice location defined by the Australian Standard Geographical Classification as inner regional to very remote. They were divided into 3 groups - 200 graduates who entered medical school before commencement of the Rural Clinical School of Western Australia (RCSWA), 63 who entered after the RCSWA had started, but not participated in RCSWA, and 61 who participated in the RCSWA. The RCSWA offers a longitudinal rural clinical clerkship throughout level 5 of the MBBS course. RESULTS The two groups not participating in the RCSWA had 45.5% and 52.4% of subjects in outer regional/very remote locations, respectively. In comparison, 78.7% of those who had participated in the RCSWA were currently practicing in outer regional/very remote locations. When the 3 groups were compared, the significant predictors of working in a more remote practice compared to working in an inner regional area were being female (OR 1.75 95% CI 1.13, 2.72, P = 0.013) and participating in the RCSWA (OR 4.42, 95% CI 2.26, 8.67, P < 0.001). In multivariate logistic regression that corrected for gender and remoteness of rural address before entry to medical school, participation in the RCSWA still predicted a more than 4-fold increase in the odds of practicing in a more remote area (OR 4.11, 95% CI 2.04, 8.30, P < 0.001). CONCLUSION Extended rural clinical clerkship during an undergraduate MBBS course is related to a much greater likelihood of practicing in more remote, under-serviced rural locations.
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Affiliation(s)
- Denese E Playford
- School of Primary, Aboriginal and Rural Health Care, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, 35 Stirling Hwy, Crawley, WA, 6009, Australia.
| | - Asha Nicholson
- School of Primary, Aboriginal and Rural Health Care, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, 35 Stirling Hwy, Crawley, WA, 6009, Australia.
| | - Geoffrey J Riley
- School of Primary, Aboriginal and Rural Health Care, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, 35 Stirling Hwy, Crawley, WA, 6009, Australia.
| | - Ian B Puddey
- Faculty Office, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, 35 Stirling Hwy, Crawley, WA, 6009, Australia.
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Sakai R, Tamura H, Goto R, Kawachi I. Evaluating the effect of Japan's 2004 postgraduate training programme on the spatial distribution of physicians. HUMAN RESOURCES FOR HEALTH 2015; 13:5. [PMID: 25617944 PMCID: PMC4328511 DOI: 10.1186/1478-4491-13-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 01/12/2015] [Indexed: 05/15/2023]
Abstract
BACKGROUND In 2004, the Japanese government permitted medical graduates for the first time to choose their training location directly through a national matching system. While the reform has had a major impact on physicians' placement, research on the impact of the new system on physician distribution in Japan has been limited. In this study, we sought to examine the determinants of physicians' practice location choice, as well as factors influencing their geographic distribution before and after the launch of Japan's 2004 postgraduate medical training programme. METHODS We analyzed secondary data. The dependent variable was the change in physician supply at the secondary tier of medical care in Japan, a level which is roughly comparable to a Hospital Service Area in the US. Physicians were categorized into two groups according to the institutions where they practiced; specifically, hospitals and clinics. We considered the following predictors of physician supply: ratio of physicians per 1,000 population (physician density), age-adjusted mortality, as well as measures of residential quality. Ordinary least-squares regression models were used to estimate the associations. A coefficient equality test was performed to examine differences in predictors before and after 2004. RESULTS Baseline physician density showed a positive association with the change in physician supply after the launch of the 2004 programme (P-value < .001), whereas no such effect was found before 2004. Urban locations were inversely associated with the change in physician supply before 2004 (P-value = .026), whereas a positive association was found after 2004 (P-value < .001). Urban location and area-level socioeconomic status were positively correlated with the change in hospital physician supply after 2004 (P-values < .001 for urban centre, and .025 for area-level socioeconomic status), even though in the period prior to the 2004 training scheme, urban location was inversely associated with the change in physician supply (P-value = .015) and area-level socioeconomic status was not correlated. CONCLUSION Following the introduction of the 2004 postgraduate training programme, physicians in Japan were more likely to move to areas with already high physician density and urban locations. These changes worsened regional inequality in physician supply, particularly hospital doctors.
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Affiliation(s)
- Rie Sakai
- />Department of Social and Behavioural Sciences, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02215 USA
- />Department of Medical Education, Juntendo University School of Medicine, Hongo 2-1-1 Bunkyo-ku, Tokyo, Japan
- />Department of Paediatrics and Adolescent Medicine, Juntendo University School of Medicine, Hongo 2-1-1 Bunkyo-ku, Tokyo, Japan
| | - Hiroshi Tamura
- />Division of Medical Information Technology and Administration Planning, Kyoto University Hospital, Sakyo-ku, Kyoto City, Kyoto, 606-8507 Japan
- />Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Sakyo-ku, Kyoto City, Kyoto, 606-8507 Japan
| | - Rei Goto
- />Hakubi Centre of Advanced Research, Kyoto University, Sakyo-ku, Kyoto City, Kyoto, 606-8501 Japan
- />Graduate School of Economics, Kyoto University, Yoshida, Sakyo-ku, Kyoto, Japan
| | - Ichiro Kawachi
- />Department of Social and Behavioural Sciences, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02215 USA
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Sakai R, Fink G, Kawachi I. Pediatricians' practice location choice-Evaluating the effect of Japan's 2004 postgraduate training program on the spatial distribution of pediatricians. J Epidemiol 2014; 24:239-49. [PMID: 24681844 PMCID: PMC4000772 DOI: 10.2188/jea.je20130117] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To explore determinants of change in pediatrician supply in Japan, and examine impacts of a 2004 reform of postgraduate medical education on pediatricians' practice location choice. METHODS Data were compiled from secondary data sources. The dependent variable was the change in the number of pediatricians at the municipality ("secondary tier of medical care" [STM]) level. To analyze the determinants of pediatrician location choices, we considered the following predictors: initial ratio of pediatricians per 1000 children under five years of age (pediatrician density) and under-5 mortality as measures of local area need, as well as measures of residential quality. Ordinary least-squares regression models were used to estimate the associations. A coefficient equality test was performed to examine differences in predictors before and after 2004. Basic comparisons of pediatrician coverage in the top and bottom 10% of STMs were conducted to assess inequality in pediatrician supply. RESULTS Increased supply was inversely associated with baseline pediatrician density both in the pre-period and post-period. Estimated impact of pediatrician density declined over time (P = 0.026), while opposite trends were observed for measures of residential quality. More specifically, urban centers and the SES composite index were positively associated with pediatrician supply for the post-period, but no such associations were found for the pre-period. Inequality in pediatrician distribution increased substantially after the reform, with the best-served 10% of communities benefitting from five times the pediatrician coverage compared to the least-served 10%. CONCLUSIONS Residential quality increasingly became a function of location preference rather than public health needs after the reform. New placement schemes should be developed to achieve more equity in access to pediatric care.
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Affiliation(s)
- Rie Sakai
- Department of Social and Behavioral Sciences, Harvard School of Public Health
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Phillips RL, Petterson S, Bazemore A. Do residents who train in safety net settings return for practice? ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2013; 88:1934-1940. [PMID: 24128640 DOI: 10.1097/acm.0000000000000025] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
PURPOSE To examine the relationship between training during residency in a federally qualified health center (FQHC), rural health clinic (RHC), or critical access hospital (CAH) and subsequent practice in these settings. METHOD The authors identified residents who trained in safety net settings from 2001 to 2005 and in 2009 using 100% Medicare Part B claims files for FQHCs, RHCs, and CAHs and 2011 American Medical Association Masterfile residency start and end date histories. They used 2009 Medicare claims data to determine the relationship between this training and subsequent practice in safety net settings. RESULTS The authors identified 662 residents who had a Medicare claim filed in their name by an RHC, 975 by an FQHC, and 1,793 by a CAH from 2001 to 2005 and in 2009. By 2009, that number of residents per year had declined for RHCs and FQHCs but increased substantially for CAHs. The percentage of physicians practicing in a safety net setting in 2009 who had trained in a similar setting from 2001 to 2005 was 38.1% (205/538) for RHCs, 31.2% (219/703) for FQHCs, and 52.6% (72/137) for CAHs. CONCLUSIONS Using Medicare claims data, the authors identified residents who trained in safety net settings and demonstrated that many went on to practice in these settings. They recommend that graduate medical education policy support or expand training in these settings to meet the surge in health care demand that will occur with the enactment of the Affordable Care Act insurance provision in 2014.
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Affiliation(s)
- Robert L Phillips
- Dr. Phillips is vice president for research and policy, American Board of Family Medicine, Washington, DC. Dr. Petterson is research director, Robert Graham Center, Washington, DC. Dr. Bazemore is director, Robert Graham Center, Washington, DC
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The impact of Japan's 2004 postgraduate training program on intra-prefectural distribution of pediatricians in Japan. PLoS One 2013; 8:e77045. [PMID: 24204731 PMCID: PMC3813669 DOI: 10.1371/journal.pone.0077045] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 09/06/2013] [Indexed: 11/19/2022] Open
Abstract
Objective Inequity in physician distribution poses a challenge to many health systems. In Japan, a new postgraduate training program for all new medical graduates was introduced in 2004, and researchers have argued that this program has increased inequalities in physician distribution. We examined the trends in the geographic distribution of pediatricians as well as all physicians from 1996 to 2010 to identify the impact of the launch of the new training program. Methods The Gini coefficient was calculated using municipalities as the study unit within each prefecture to assess whether there were significant changes in the intra-prefectural distribution of all physicians and pediatricians before and after the launch of the new training program. The effect of the new program was quantified by estimating the difference in the slope in the time trend of the Gini coefficients before and after 2004 using a linear change-point regression design. We categorized 47 prefectures in Japan into two groups: 1) predominantly urban and 2) others by the definition from OECD to conduct stratified analyses by urban-rural status. Results The trends in physician distribution worsened after 2004 for all physicians (p value<.0001) and pediatricians (p value = 0.0057). For all physicians, the trends worsened after 2004 both in predominantly urban prefectures (p value = 0.0012) and others (p value<0.0001), whereas, for pediatricians, the distribution worsened in others (p value = 0.0343), but not in predominantly urban prefectures (p value = 0.0584). Conclusion The intra-prefectural distribution of physicians worsened after the launch of the new training program, which may reflect the impact of the new postgraduate program. In pediatrics, changes in the Gini trend differed significantly before and after the launch of the new training program in others, but not in predominantly urban prefectures. Further observation is needed to explore how this difference in trends affects the health status of the child population.
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Health inequalities and regional specific scarcity in primary care physicians: ethical issues and criteria. Int J Public Health 2013; 59:449-55. [PMID: 23880912 DOI: 10.1007/s00038-013-0497-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Revised: 05/24/2013] [Accepted: 07/11/2013] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVES A substantial body of evidence supports the beneficial health impact of an increase in primary care physicians for underserved populations. However, given that in many countries primary care physician shortages persist, what options are available to distribute physicians and how can these be seen from an ethical perspective? METHODS A literature review was performed on the topic of primary care physician distribution. An ethical discussion of conceivable options for decision makers that applied prominent theories of ethics was held. RESULTS Examples of distributing primary care physicians were categorised into five levels depending upon levels of incentive or coercion. When analysing these options through theories of ethics, contrasting, and even controversial, moral issues were identified. However, the different morally salient criteria identified are of prima facie value for decision makers. CONCLUSIONS The discussion provides clear criteria for decision makers to consider when addressing primary care physician shortages. Yet, decision makers will still need to assess specific situations by these criteria to ensure that any decisions they make are morally justifiable.
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Abstract
Giorgio Cometto and colleagues discuss the study by Tankwanchi and colleagues on physician migration to the United States from sub-Saharan Africa and the steps that the US, other destination countries, and SSA countries can take to address the problem. Please see later in the article for the Editors' Summary
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Affiliation(s)
- Giorgio Cometto
- Global Health Workforce Alliance, World Health Organization, Geneva, Switzerland
- * E-mail:
| | - Kate Tulenko
- IntraHealth International, Washington (D.C.), United States of America
| | | | - Ruediger Krech
- Department of Ethics and Social Determinants of Health, World Health Organization, Geneva, Switzerland
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Runkle JD, Brock-Martin A, Karmaus W, Svendsen ER. Secondary surge capacity: a framework for understanding long-term access to primary care for medically vulnerable populations in disaster recovery. Am J Public Health 2012; 102:e24-32. [PMID: 23078479 PMCID: PMC3519329 DOI: 10.2105/ajph.2012.301027] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2012] [Indexed: 11/04/2022]
Abstract
Disasters create a secondary surge in casualties because of the sudden increased need for long-term health care. Surging demands for medical care after a disaster place excess strain on an overtaxed health care system operating at maximum or reduced capacity. We have applied a health services use model to identify areas of vulnerability that perpetuate health disparities for at-risk populations seeking care after a disaster. We have proposed a framework to understand the role of the medical system in modifying the health impact of the secondary surge on vulnerable populations. Baseline assessment of existing needs and the anticipation of ballooning chronic health care needs following the acute response for at-risk populations are overlooked vulnerability gaps in national surge capacity plans.
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